- REITER'S DISEASE* BY A. H. HARKNESS Joint-Director Endell Street Clinic, St. Peter's and St. Paul's Hospital (Institute of Urology); Consultant in. Venereal Diseases to- St. -Charles' Hospital; the Civil Consultant in Venereal Diseases to the Royal Navy Reiter's disease is characterized by a clinical joint. This appears to me to have been a clear syndrome consisting of a primary abacterial ure- case of the dysenteric syndrome. -Description of thritis of venereal origin, bilateral conjunctivitis, the syndrome, until the oetiology is established, polyarthritis, frequently balanitis, and sometimes would be facilitated if a distinct differentiation keratodermia blennorrhagica; cardiac and other were made between cases of venereal and those of manifestations have also been described.- The dysenteric origin. I advocated in 1947 that the, itiology is unknown. term " Reiter's disease," or better still " dysenteric There is an almost identical syndrome associated arthritis," be applied only to the latter, and that with the various types of dysentery (the primary the former-those of venereal origin-be described focus of infection in these cases is the bowel and as " non-gonococcal polyarthritis " or " the non- not the urethra) which is probably the same disease. gonococcal syndrome." Much confusion would, There are also certain other diseases and reactions I am convinced, be avoided by such a distinction. due -to treatment which may simulate the syndrome The venereal syndrome, as we know it today, very closely. was recognized many years before Reiter published In my experience true Reiter's disease is one in his case, indeed a case in which the syndrome was which the primary focus of infection is an abacterial complete was described by Launois in 1899. In urethritis of venereal origin with blood-borne this instance there had been five previous attacks complications. (In none of my cases have I of gonorrhoea, the syndrome developing during an observed dysenteric symptoms nor have any of attack of urethritis in which gonococci could not them shown a previous history of dysentery.) The be found in the discharge or urine, the latter being syndrome may be complete or incomplete. It is heavily infected with Bacillus coli. commonly pyrexial, sometimes runs a protracted Priority in the description of the syndrome course, and often recurs after short or long periods urethritis, conjunctivitis, and arthritis, however, of remission. In my series two separate attacks should be accorded to Sir Benjamin Bilodie, who in occurred in twenty-four patients, three in four, 1818 gave a full description of one typical case and and four in one: the syndrome was never complete referred in some detail to four others.t in more than one attack. Two of the original forty-four cases of abacterial It has frequently been reported to me by my male urethritis of venereal origin described by Wmlsch nurses at St. Charles's Hospital that patients with in 1916 developed blood-borne complications, one the syndrome, including those acutely ill, invariably rheumatic pains in both knees and ankles, and the have voracious appetites. other bilateral conjunctivitis two days- after the From the many references to Reiter's - disease urethral discharge was noticed. Inflammation of which have appeared. recently in the literature, it the eyes reappeared four months later following seems that several misconceptions exist on the intercourse with the same woman. Wwelsch (1916) subject. Much of the confusion would' appear considered that the eyes were infected by fingers to be due to the fact that the disease bears Reiter's contaminated with the urethral secretion. name. In his case, reported in 1916, the illness was In dealing with this subject it is difficult to know ushered in with severe abdominal pain, diarrhoea how many of the clinical entities of the syndrome and blood-stained stools, followed eight days later are necessary before it is possible to make a by a purulent -urethral discharge with bilateral diagnosis of Reiter's disease. Should only the conjunctivitis. On the ninth day there was an cases in which the syndrome is complete be re- acute polyarthritis, and six weeks later numerous viewed, or should the primary focus of infection, pustules were noted in the region of the left hip together with one, two, or three of the blood-borne An Address to the Medical Society for the Study of Venereal Diseases, April 29, 1949. t This was brought to my notice by my friend Robert Milne. c 185 186 BRITISH JOURNAL OF VENEREAL DISEASES TABLE I complications of bilateral conjunctivitis, arthritis, and keratodermia blennorrhagica. Details of this series are given in Table I. I shall also include twelve cases in which the gonococcus was present 0 in the urethral discharge before the commencement U, of treatment for urethritis (Table II). It is pre- sumed that penicillin destroyed the gonococcal element in the urethral discharge and that the residual abacterial infection caused the subsequent 2 + + + - - - development of blood-borne complications. 6oplcaios182S + warn+- + hiicuini th decrip All the patients included in Tables I and II were tin?Gnuciiisi omnyml andehm males. The disease is extremely rare in females; 25 + + - + - - + 8 + - - + -. indeed there -are many workers who maintain that 2 + - - - - + - it never occurs in women. In 1945 I was able to 1 + - - - + - - fihid only nine cases of keratodermia blennorrhagica recorded in women (Harkness, 1945). I have had complications warrantt their inclusion in the descrip- two cases in which a non-gonococcal cervical tion? Conjunctivitis is commonly mild ~tnd ephem- discharge (cultures for " L" organisms being eral; the balanitis and keratodermia blennorrhagica positive in both) was associated with polyarthritis (unless generalized) are often inconspicuous and and typical lesions of keratodermia blennorrhagica symptomless; the three conditions are therefore (one also suffered from bilateral conjunctivitis); easily overlooked as they have been in tnany cases and I saw recently a similar case with Harman. I of polyarthritis referred to me for treatment. On have had other cases of polyarthritis in women with the other hand the arthritic manifestation of the a non-gonococcal cervicitis in which " L " organisms disease is invariably disabling and was present in have been cultured, but the absence of skin lesions all the cases described in the literature except the made the diagnosis extremely difficult. As will be third case of Stuihmer's series, Roth's case, and seen later, a number of cases have been reported thirteen of mine which are described below. in women in association with the dysenteric Many of the doubtful cases described in the syndrome. literature, including that of Lojander (1927), in Sequence of Syndrome which there was no evidence of infection in the urinary tract, are commonly associated with atypical In my series of cases in which it was possible to skin lesions, usually hyperkeratotic rupial patches observe the progression of the disease, conjunctivitis and not nodules. However, in one of my cases, in was noted one to eighteen days (commonly six) which there were three attacks, the syndrome was after the appearance of the urethral discharge, and complete during the first illness and in the third a arth,ritis one to six days later. In two cases unilateral iritis and polyarthritis occurred with no arthralgic pains in several joints were noted before signs or symptoms in the urinary tract. the onset of conjunctivitis. Definite articular In my description of the venereal syndrome I involvement did not occur until a few days later. shall include all cases ofprimary abacterial urethritis Bilateral conjunctivitis associated with arthralgic together with one or more of the blood-borne pains and myositis with no subsequent development ofarthritis was observed in two cases: conjunctivitis TABLE II was not noted in two other cases associated with PRIMAR-Y MIXED INFECTIONS (GONOCOCCAL AND NON- arthralgia only. GONOCOCCAL) It must be emphasized, however, that in many cases, including some in which the syndrome has No. Abacterial Ocular Kerato~- progressed to include keratodermia blennorrhagica, of gonococcal mani- Arthritis bernnrrhagica- conjunctivitis has been either absent or so mild cases festations that it has been overlooked. This smay be the explanation for the two cases with unilateral iritis 7 + - which were not observed until two weeks after the 3 + + onset of arthritis. + Balanitis is commonly noted soon after the onset of arthritis and always before the appearance of No cases from the pre-penicillin era are included. Blood-borne complications occurred one to twenty-six days after successful the rash. Early lesions of keratodermia blennor- penicillin therapyfor the gonococcal element in the urethral discharge. rhagica were noted in one case on the same day as RElTER'S DISEASE 187 the arthritis, but in all other cases it was not observed instrument, is frequently observed in this type of until at least a month after the onset of the disease. urethritis, whereas " organic " stricture requiring dilatation treatment, observed in seven cases, was Urethritis and other Manifestations in the probably due to previous gonococcal inflammation. Urinary Tract The primary focus of infection, in the majority Acpte Onset of Urethritis is distinguished by a of cases, is a non-gonococcal abacterial urethritis. profuse muco-purulent or purulent urethral dis- This is commonly ushered in with signs and symp- charge simulating gonorrhoea, and